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Injections and Infusions Coding Handbook

Hospital Outpatient EditionPub Code


Hospital Outpatient Edition

Drug administration is one of the most common services provided in the outpatient setting, and while the rules and codes have not changed significantly since 2009, coders still have questions about how to apply the CPT® guidelines and follow CMS' guidance.

This handbook begins with a review of drug administration concepts, including definitions of common terms. It then walks through the hierarchy that outpatient facility coders use to select the initial drug administration service. The handbook also explains how to properly de-termine when to report concurrent, subsequent, and additional hours of substances and when to report hydration.

Included are 15 case examples of varying complexity for coders to test their understanding of drug administration principles. The correct coding for each example is provided, along with explanations highlight-ing key code assignment concepts. The handbook concludes with some frequently asked questions about drug administration.

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JCGII

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Injections and Infusions

Coding Handbook

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JustCoding’s Injections and Infusions Coding Handbook is published by HCPro, a division of BLR

Copyright © 2015 HCPro

All rights reserved. Printed in the United States of America. 5 4 3 2 1

ISBN: 978-1-55645-526-1

No part of this publication may be reproduced, in any form or by any means, with-out prior written consent of HCPro or the Copyright Clearance Center (978-750-8400). Please notify us immediately if you have received an unauthorized copy.

HCPro provides information resources for the healthcare industry.

HCPro is not affiliated in any way with The Joint Commission, which owns the JCAHO and Joint Commission trademarks.

CPT copyright 2015 American Medical Association. All rights reserved. CPT and CPT Assistant are registered trademarks of the American Medical Association.

Jugna Shah, MPH, ReviewerMichelle A. Leppert, CPC, EditorMelissa Osborn, Product ManagerErin Callahan, Senior Director, ProductElizabeth Petersen, Vice PresidentMatt Sharpe, Production SupervisorVincent Skyers, Design Services DirectorVicki McMahan, Sr. Graphic Designer/LayoutMichael McCalip, Cover Designer

Advice given is general. Readers should consult professional counsel for specific legal, ethical, or clinical questions.

Arrangements can be made for quantity discounts. For more information, contact:

HCPro100 Winners Circle, Suite 300Brentwood, TN 37027Telephone: 800-650-6787 or 781-639-1872Fax: 800-639-8511E-mail: [email protected]

Visit HCPro online at: www.hcpro.com and www.hcmarketplace.com

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© 2015 HCPro Injections and Infusions Coding Handbook | iii

Contents

About the Reviewer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Chapter 1: Drug Administration Basics . . . . . . . . . . . . . . . . . . . . . . . 3

Chapter 2 : CPT Coding for Drug Administration . . . . . . . . . . . . . . . . 7

IV Infusion and Injection Facility Coding Drug Administration Hierarchy . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Subsequent and Sequential Infusions . . . . . . . . . . . . . . . . . . . . . . 10

Concurrent Infusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Infusion and IV Push of Same Substance . . . . . . . . . . . . . . . . . . . 14

Hydration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Long-Duration IV Pushes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Encounters That Cross Midnight . . . . . . . . . . . . . . . . . . . . . . . . . 19

Modifier -59 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Drug Administration Decision Tree . . . . . . . . . . . . . . . . . . . . . . . 24

Chapter 3: Documentation for Drug Administration . . . . . . . . . . . . . . 27

Physician Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Nurse Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Chapter 4: Case Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Case Study 1: Multiple IV Pushes . . . . . . . . . . . . . . . . . . . . . . . . 31

Case Study 2: Multiple IV Pushes . . . . . . . . . . . . . . . . . . . . . . . . 31

Case Study 3: IV Push and Hydration . . . . . . . . . . . . . . . . . . . . . 32

Case Study 4: Chemotherapy and IV push . . . . . . . . . . . . . . . . . 32

Case Study 5: Chemotherapy with Multiple Other Services . . . . . . 32

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iv | Injections and Infusions Coding Handbook © 2015 HCPro

Contents

Case Study 6: Chemotherapy and IV Pushes . . . . . . . . . . . . . . . . 33

Case Study 7: Multiple Drug Administration Services with Different Routes with Hydration . . . . . . . . . . . . . . . . . . . . . . 33

Case Study 8: Encounter That Crosses Midnight . . . . . . . . . . . . . . 33

Case Study 9: Hydration That is Stopped and Started . . . . . . . . . 34

Case Study 10: IV Push and Hydration . . . . . . . . . . . . . . . . . . . . 34

Case Study 11: Multiple Infusions of the Same Drug . . . . . . . . . . . 34

Case Study 12: Overlapping Infusions . . . . . . . . . . . . . . . . . . . . 34

Case Study 13: Infusion with No Stop Time . . . . . . . . . . . . . . . . . 35

Case Study 14: Infusion and Multiple Pushes . . . . . . . . . . . . . . . . 35

Case Study 15: Concurrent Infusions with Different End Times . . . . . 35

Chapter 5: Case Study Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Case Study 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Case Study 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Case Study 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Case Study 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Case Study 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Case Study 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Case Study 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Case Study 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Case Study 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Case Study 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Case Study 11 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Case Study 12 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Case Study 13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Case Study 14 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Case Study 15 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

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© 2015 HCPro Injections and Infusions Coding Handbook | v

Contents

6: Frequently Asked Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

FAQ 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

FAQ 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

FAQ 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

FAQ 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

FAQ 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

FAQ 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

FAQ 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

FAQ 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

FAQ 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

FAQ 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

FAQ 11 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

FAQ 12 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

FAQ 13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

FAQ 14 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

FAQ 15 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

FAQ 16 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

FAQ 17 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

FAQ 18 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

FAQ 19 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

FAQ 20 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

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© 2015 HCPro Injections and Infusions Coding Handbook | vii

About the Reviewer

Jugna Shah, MPH, is the president and founder of Nimitt Consulting

Inc. (www.nimitt.com), a firm specializing in case-mix payment system

design, development, and implementation. She has extensive experi-

ence helping providers understand and address the ongoing clinical,

operational, and financial implications of Medicare’s Outpatient Pro-

spective Payment System (OPPS) based on APCs.

She has educated and audited hospitals on their drug administration

coding and billing practices. She has contributed to several books

and numerous OPPS/APC articles over the past 12 years. She is also

a contributing editor for HCPro’s Briefings on APCs.

Shah works with a variety of U.S. hospitals and health systems to

address the clinical, operational, and financial challenges of Medi-

care’s payment systems, particularly OPPS. She helps providers

address and overcome complex coding, billing, revenue cycle, and

compliance issues, with a focus on medical and radiation oncology,

pharmacy and drug reporting and coverage, reporting observation

and visits, and much more. She also provides consulting guidance to

drug and device manufacturers, trade associations, consulting, audit-

ing, and law firms on reimbursement, compliance, regulatory, and

coverage issues.

Shah works extensively on international case-mix design, system

development, and implementation initiatives. She has led many

World Bank and U.S. Agency for International Development

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viii | Injections and Infusions Coding Handbook © 2015 HCPro

About the Reviewer

healthcare financing reform initiatives to provide long-term policy

and technical assistance to foreign governments. She has led proj-

ects in Albania, Bulgaria, the Czech Republic, Hungary, Iceland, the

Republic of Moldova, Romania, Turkey, and Slovakia.

Since 2007, Shah has served on the Executive Committee of Patient

Classification Systems International (PCSI), an international case-mix

organization. She is currently the PCSI vice president.

Shah is a popular and dynamic educator who regularly writes and

presents on OPPS, IPPS, APCs, DRGs, and related healthcare topics.

She is a frequent speaker at local, regional, national, and interna-

tional conferences and helped create several of the field’s leading

publications on OPPS/APCs, including HCPro’s APC Insider and Briefings on APCs.

Prior to founding Nimitt Consulting, Inc., Shah was a senior manager

with KPMG’s Assurance-Based Advisory Services Practice, guiding

providers through the clinical and financial implications of APC

implementation. Previously, Shah worked with 3M Health Informa-

tion Systems as an ambulatory care product marketing manager. She

holds a bachelor of science in biopsychology from Oberlin College

and a masters of public health policy and administration from the

University of Michigan.

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© 2015 HCPro Injections and Infusions Coding Handbook | 1

Introduction

Experienced and novice outpatient facility coding professionals

alike struggle with coding drug administration services. Even

though the American Medical Association hasn’t made major

changes to the CPT codes and guidelines for these services since

2009, coding professionals often question whether they are report-

ing these services correctly.

JustCoding’s Injections and Infusions Coding Handbook will help

reduce the worry by clearly and concisely reviewing common drug

administration terms and concepts, including the drug administration

hierarchy. This easy-to-use handbook also covers concurrent and

subsequent infusions, hydration, and proper use of modifier -59 (dis-

tinct procedural service). In addition, the handbook includes a chap-

ter on documentation requirements for both physicians and nurses.

The handbook then lets coding professionals put their knowledge

to the test with 15 drug administration case studies. The case stud-

ies range from simple to complex and cover a wide range of topics

addressed in the earlier chapters of the handbook. The answers and

explanations appear in the following chapter.

The handbook closes with some frequently asked questions about

drug administration reporting. Coding professionals can refer back

to the concepts and case studies to refresh their knowledge or help

them solve a confusing case.

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1Drug Administration Basics

Coding for drug administration services can be confusing for

both veteran and new coding professionals because the drug

administration guidelines are very different from how CPT®

requires coding professionals to report most other services. Addition-

ally, some of the drug administration information in the CPT Manual

is only intended for facility reporting, and some of the guidance from

CPT is not applicable at all for facility coding, as CMS has provided

different guidance.

In addition, coding professionals often receive conflicting information

and in some cases, lack clear guidance altogether.

Coding professionals must be savvy and put information from CPT,

CMS, and their Medicare Administrative Contractor (MAC) together

to arrive at a complete picture for how to report drug administration

services. Most of the confusion surrounding drug administration

services centers around reporting intravenous (IV) injection and infu-

sion services. Therefore, this book is focused on the nuances related

to reporting those services completely and accurately.

Physician and nursing documentation may also create problems

with being able to report drug administration services, especially for

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4 | Injections and Infusions Coding Handbook © 2015 HCPro

Chapter 1

time-based services such as chemotherapy, therapeutic infusions, and

hydration. IV drug administration services provided in the outpatient

setting are delivered using two routes of administration:

• Infusion: involves the administration of IV fluids and/or drugs

over a period of time for diagnostic or therapeutic purposes.

• Injection: delivers a dosage in one ‘shot,’ either very quickly

or in some cases over a period of time where the healthcare

provider is continuously present to administer the injection

either subcutaneously, intramuscularly, intra-arterially, or

intravenously.

The types of drugs and medication are divided into three main

categories:

• Chemotherapy: the use of medicine or drugs to treat cancer

delivered by various routes of administration. The CPT Manual

also includes other highly complex drugs and highly complex

biological agents in this category.

• Nonchemotherapy: includes therapeutic, prophylactic, and diag-

nostic medicines and drugs delivered by a variety of routes.

• Hydration: solution may include a combination of sugar and

carbohydrates (for energy), electrolytes, and trace elements

delivered by infusion (hanging a bag with fluids).

Medication that is given for an immediate effect (typically within

3-5 minutes) is an injection. Medication or solution that is provided

through saline or other solutions given over a period of time is an

infusion.

The rules and guidelines for coding drug administration services

differ slightly between physician and facility. In this handbook, we

will look specifically at the coding for IV infusion and injection drug

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Drug Administration Basics

administration services subject to the CPT coding hierarchy provided

in hospital outpatient departments or facilities.

The hierarchy sets out how coding professionals should report multi-

ple injections and infusions provided on the same day or during the

same encounter.

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2 CPT Coding

for Drug Administration

The CPT Manual divides drug administration services into three

different categories:

• Hydration (CPT codes 96360–96361)

• Therapeutic, prophylactic, and diagnostic injections and infu-

sions (96365–96379)

• Chemotherapy and other highly complex drug or highly com-

plex biologic agent administration (96401–96549)

Each section of codes includes some that have the word “initial” as

part of the code description, while others do not. Coding profession-

als will find add-on codes that may be used in conjunction with what

is usually thought of as the parent code, usually the code that comes

right before the add-on code in the CPT Manual. In the case of drug

administration codes, these add-on codes may be used alongside

other codes that are not necessarily the parent code.

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Chapter 2

What is critical to note is that the IV injection and infusion drug

administration CPT codes are subject to a coding hierarchy that is

applicable to the facility setting and not the physician-office setting.

According to the facility CPT coding hierarchy, chemotherapy ser-

vices are primary to therapeutic, prophylactic, and diagnostic ser-

vices, which are primary to hydration services. Infusions are primary

to pushes, which are primary to injections.

Note that IV push injections are subject to the hierarchy. Subcuta-

neous (SQ) and intramuscular (IM) injections are not, as they do not

contain the word “initial” in their descriptors nor are they IV ser-

vices, which is what the facility coding hierarchy focuses on.

IV Infusion and Injection Facility Coding Drug Administration HierarchyRemember, the hierarchy applies to all IV injection and infusion ser-

vices. Chemotherapy services are primary and should be selected as

initial when provided in conjunction with therapeutic, prophylactic,

or diagnostic services.

This hierarchy also supersedes parenthetical instructions for add-on

codes that in some cases may suggest an add-on of a higher hierar-

chical position to be reported in conjunction with a base code of a

lower position, according to the CPT Manual.

In other cases, information may be missing from the parenthetical

instructions. Use parenthetical notes in conjunction with the hierarchy,

but allow the hierarchy to take precedence as that will lead to correct

coding each time. If you have questions, check with CPT, submit a

question to the American Hospital Association, and reach out to your

MAC.

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CPT Coding for Drug Administration

One code in each of the drug administration categories below, as

directed by the CPT Manual, has been designated as the “initial”

service:

• Chemotherapy and other highly complex drug or highly com-

plex biologic agent administration

– Infusion (initial)

– IV push (initial)

– IM/SQ (no mention of initial)

– Others (many other codes exist in the section, but there is

no use of the word “initial” since they are not IV services)

• Therapeutic/prophylactic/diagnostic injection and infusion

– Infusion (initial)

– IV push (initial)

– IM/SQ (no mention of initial)

• Hydration (initial)

Services can be provided concurrently or sequentially.

A concurrent service CPT code exists for an infusion service. Report

this code when a new substance or drug is infused at the same time

as another substance or drug. Concurrent infusions (CPT add-on

code 96368) are only reported once per day regardless of whether

the concurrent infusion lasts for multiple hours or whether additional

drugs or substances are administered concurrently.

Sequential services can be thought of as services that occur before

or after another. They can be infusions or injections. Coding profes-

sionals need to know whether the same substance or drug is being

administered because CPT includes different codes for reporting an

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Chapter 2

infusion or injection of the same substance or drug versus a new

substance or drug.

Coding professionals also need to remember that the order of the

service delivery does not determine what’s initial. Even if a patient

receives hydration first, followed by a therapeutic infusion, and then

finally chemotherapy, the chemotherapy would be reported as the

initial service according to the hierarchy.

Typically, coding professionals will report only one initial service per

visit, unless the patient has more than one access site. So if a patient

receives hydration with IV pushes, with therapeutic infusions, or with

chemotherapy, coding professionals can report hydration, but not as

an initial service unless a separate IV line was started for it.

Subsequent and Sequential InfusionsThe codes for subsequent and sequential infusions are add-on codes.

Think of these infusions as ones occurring one after another or an

infusion that comes before or after an initial service.

Sequential infusions denote the administration of either a new drug

or substance or the same drug or substance; knowing this is critical

in selecting the correct code. Coding professionals can report these

codes once per encounter for the same drug or infusate. If multiple

different drugs or infusates are administered, then coding profes-

sional can report multiple sequential infusion codes.

Coding professionals can report 96366 (intravenous infusion, ther-

apy, prophylaxis, or diagnosis; each additional hour) for additional

hours of an initial infusion or additional hours of an infusion of a

different substance or drug. This is an important concept because a

single code is used to report two different things–additional hours as

well as additional infusions.

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If the same drug is infused multiple times, CPT code 96366 must

be used to report these infusions. This is not intuitive, since coding

professionals usually think of this code as being used to report addi-

tional hours, yet 96366 is also used to report additional infusions of

the same drug. In summary, use CPT 96366 to report each of the

following:

• Additional hours of the initial service infusion

• Additional hours of a sequential infusion, which means addi-

tional hours of an infusion of a new drug

• Additional infusions of the same substance or drug

For a sequential infusion of a new nonchemotherapy drug or infu-

sate, report 96367 (intravenous infusion, therapy, prophylaxis, or

diagnosis; additional sequential infusion, [list separately in addition to

code for primary procedure] up to one hour), and for a chemother-

apy sequential infusion, use 96417.

Coding professionals can report codes that include subsequent/

sequential in their descriptions even if those codes are the first ser-

vice in a group of services (e.g., an IV push given in addition to an

initial one-hour infusion must be reported with the subsequent IV

push code even though there is no initial IV push code).

It is not intuitive to report a subsequent service add-on code from

one drug administration section of the CPT Manual, such as in the

example given about with an IV push and a therapeutic infusion or

in the case with hydration and other IV drug administration services.

It is necessary in order to be compliant with the CPT coding hierar-

chy that facilities must follow. When a patient receives a chemother-

apy infusion and prehydration, coding professionals should report

hydration code 96361, essentially a subsequent service add-on

code, even though they do not report what may be considered the

parent code, 96360. In this case, the parent code is actually the

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Chapter 2

chemotherapy infusion CPT code 96413. This may seem counter-

intuitive because it comes from the chemotherapy section of CPT

rather than the hydration section.

This is often not intuitive to those new to reporting facility drug

administration services because it does not follow traditional CPT

coding convention of add-on codes, but it is necessary to be compli-

ant with the CPT coding hierarchy rules.

For example, facilities may report a sequential IV push of the same

drug using CPT code 96376. This code is used to report multiple

IV pushes of the same substance or drug, only if 30 minutes elapse

between the reported pushes. This code is also used to report an

infusion and an injection of the same substance or drug.

In other words, if a nonchemotherapy drug is infused and then the

same drug is given by IV push, facilities would report 96376 for the

injection and 96365 for the infusion. Note that 96376 is only for

facility reporting of each additional sequential push of the same sub-

stance or drug.

Coding professionals should hone in on the phrase ‘new substance or

drug.’ Various codes are available for reporting sequential infusion

and injection services. Coding professionals will determine which

code to use based on whether the drug is the same or different.

For example, multiple infusions of the same substance or drug are

reported with add-on code 96366, which may not be intuitive since

this code is typically used to report additional hours of an infusion

but can also be used to report additional infusions of the same sub-

stance or drug.

If the provider is not infusing a new substance, coding professionals

should not report the sequential infusion code, but instead should

follow the CPT instruction that points to using the additional hours

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code to report additional infusions of the same substance or drug if

the time requirements are met.

Concurrent InfusionsUnlike subsequent infusions that can run before or after an initial

infusion, concurrent infusions run at the same time as another infu-

sion. The CPT code for a concurrent infusion is also an add-on code

and should be reported when multiple infusions are running simul-

taneously through the same line. CPT includes only one concurrent

code, and it is for nonchemotherapy infusion. If a patient receives

concurrent chemotherapy infusions, coding professionals should

report unlisted chemotherapy administration code 96549.

Substances mixed together in one bag are considered one infusion—

not concurrent. In addition, there is no concurrent infusion code

for hydration. In fact, if hydration is provided at the same time as

another infusion, it cannot be reported separately with a CPT code.

In other words, there is no separate payment available for hydration

running concurrently to another infusion.

Coding professionals can assign the concurrent code when a patient

receives chemotherapy and a therapeutic infusion simultaneously

into the same line. They can also report it when the patient receives

two different nonchemotherapy drugs at the same time through the

same line.

Reporting the concurrent infusion code has raised many questions,

including whether the infusions have to run for exactly the same

time or whether a certain amount of overlap qualifies in reporting

the concurrent infusion code.

The CPT Manual doesn’t provide guidance on this, but CPT Assistant

archives (4th Quarter 1990–present) 2009 Coding Update: Infusion

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Chapter 2

/ Injection Services (February 2009, Volume 19, Issue 2, pages

17–21), provides some insight.

The answer there indicates that if the majority of one of the infu-

sions is sequential in nature, not running at the same time as the

other infusion, then reporting the sequential infusion service code

would be more appropriate.

This essentially indicates that either the concurrent or the sequential

code can be reported but that the sequential code may be more

appropriate if the majority of the time is not concurrent.

Coding professionals should recall that when the concurrent code is

reported, it is reported with a unit of one, signifying that the service

being reported is concurrent in nature. Remember that additional

hours of a concurrent infusion cannot be reported.

Infusion and IV Push of Same SubstanceWhen a patient receives a therapeutic infusion of a drug for one

hour, coding professionals know to report CPT code 96365 (intra-

venous infusion, for therapy, prophylaxis, or diagnosis [specify sub-

stance or drug]; initial, up to 1 hour).

That same patient receives an IV push of the same drug. Coding pro-

fessionals know they should report an IV push code; however, they

don’t always know which one is appropriate.

Many coding professionals are confused about whether to report

CPT code 96375 (therapeutic, prophylactic, or diagnostic injection

[specify substance or drug]; each additional sequential intravenous

push of a new substance/drug) or 96376 (therapeutic, prophylactic

or diagnostic injection [specify substance or drug]; each additional

sequential intravenous push of the same substance/drug in a facility).

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CPT instructs that 96376 should be reported for the push even

though an initial push code is not present. The key to understanding

the guideline is to remember that it’s the same drug—first as an IV

infusion and then as an IV push.

Coding professionals may also be confused by CPT’s clarification

involving multiple infusions.

According to CPT guidelines:

When reporting multiple infusions of the same

drug/substance on the same date of service, the initial code

should be selected. The second and subsequent infusion(s)

should be reported based on the individual time(s) of each

additional infusion(s) of the same drug/substance using the

appropriate add-on code.

Coding professionals should focus on the terms “multiple infusions,”

“same drug or substance,” and “based on the individual time(s).”

Coding professionals know to report the sequential infusion code

(i.e., 96367 or 96417) when reporting an additional or subsequent

infusion of a different substance or drug, but when it’s the same

drug, confusion often occurs and questions arise about adding

together the times.

In cases where the same drug is being infused multiple times, coding

professionals must examine the time of each individual infusion as

stated in CPT and report them using the additional hours infusion

code. Because each individual infusion must be looked at in terms of

time, the time requirements for reporting infusions should be utilized

(i.e., was the infusion 15 minutes or less or more than 15 minutes).

Remember, add-on codes for drug administration services don’t nec-

essarily follow the standard way that coding professionals normally

think about using add-on codes, which usually involves the main or

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Chapter 2

parent code before using the add-on code. That is not the case for

drug administration services.

The CPT Manual illustrates how the guideline is applied: In the out-

patient observation setting, a patient receives hourlong IV infusions

of the same antibiotic every eight hours on the same date of service

through the same IV access. Coding professionals should report CPT

code 96365 for the first one-hour dose administered and add-on

code 96366 twice (i.e., once for the second hourlong infusion and

once for the third hourlong infusion of the same drug).

It might look to coding professionals like CPT is adding up the times

of the three infusions of the same substance or drug, but that is not

what is happening. CPT guidelines state, ‘the second and subsequent

infusion should be reported based on the individual times of each

infusion.’

If the patient receives the same drug infused multiple times, each

infusion must be reported according to its own time. Moreover, if

one of the infusions is longer and meets the time requirement of

reporting an additional hour, then it would be reported with 96366,

and the additional time would also be reported using the same

96366 add-on code.

Again, this may not seem intuitive, but for now it’s the only code

available to report both additional hours of an infusion as well as

multiple infusions of the same substance or drug.

Coding professionals need to remember to report additional infu-

sions of that same substance or drug using the additional hours code,

not the sequential infusion code, as that is for a different substance

or drug. They also need to remember that the add-on code has mul-

tiple uses.

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Hospital Outpatient EditionPub Code


Hospital Outpatient Edition

Drug administration is one of the most common services provided in the outpatient setting, and while the rules and codes have not changed significantly since 2009, coders still have questions about how to apply the CPT® guidelines and follow CMS' guidance.

This handbook begins with a review of drug administration concepts, including definitions of common terms. It then walks through the hierarchy that outpatient facility coders use to select the initial drug administration service. The handbook also explains how to properly de-termine when to report concurrent, subsequent, and additional hours of substances and when to report hydration.

Included are 15 case examples of varying complexity for coders to test their understanding of drug administration principles. The correct coding for each example is provided, along with explanations highlight-ing key code assignment concepts. The handbook concludes with some frequently asked questions about drug administration.

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Injections and Infusions - hcmarketplace.com and Infusions Coding Handbook ... World Bank and U.S. Agency for International Development ... coding professionals often question …